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  2013 Jeff Wyand Miracle Ride
  Saturday, August 17th, 2013

   Offline Registration Form  

 

Rider:

Passenger:

Address:

Address:

City:

City:

State:

State:

Zip Code:

Zip Code:

Email Address:

Email Address:

Home Phone:

Home Phone:

 

 

 

Cruiser $25 (1 rider, 1 ticket to BBQ)

 

 

Additional Donations: $

 

 

 

 

 

 

 

 

For Office Use Only:

Payment Method:

Cash/Money Order

Check

Credit Card

Amount Received:

$

$

$

 



Accident/Injury Liability Waiver
I understand that my participation in the 2013 Jeff Wyand Miracle Ride involves inherent risks of personal injury, property damage or loss. I further understand that my participation in this event is totally voluntary and done at my own risk, and I acknowledge that I am responsible for my participation in this event. I represent and affirm that I will wear any and all required protective equipment and obey all applicable laws and rules of the road. In consideration of Fletcher Allen Health Care permitting me to participate in this event, I hereby, for myself and my heirs, executors, administrators, successors, and assigns, waive and release any and all rights and claims of any nature I may have against Fletcher Allen Health Care and any of its affiliates, subsidiaries, chapters, assignees, licensees, and cooperating entities, and any of their officers, directors, employees, agents, and representatives, and their heirs, executors administrators, successors, and assigns, for any and all injuries, damages, or losses of any nature that I may suffer as a result of taking part in this event or any activities connected herewith. I will not hold Fletcher Allen Health Care responsible for any injuries, damages, or losses incurred by me as a result of my participation in this event. Consent is also given to use my name, picture or portrait, writings or biographical information, as well as audio tape or videotape recordings and sound or silent motion pictures of me in any media for editorial, educational, promotional, and advertising purposes for the solicitation of contributions and for any other purposes in furtherance of the objectives of Fletcher Allen Health Care. This release and consent shall be binding upon my heirs, executors, administrators or assigns.

 

RIDER: In addition to the above statements, as the operator of the motorcycle, I represent and affirm that I am in all ways fit, qualified, and licensed to ride a motor vehicle.

 

PASSENGER: 

Signature:

Signature:

Print Name:

Print Name:

Date:

Date:

 

***IMPORTANT: All participants are required to sign an accident/injury liability waiver.***

 Submit this form by August 2nd, 2013 to:

FAX:
802-847-2817            
EMAIL: development@vtmednet.org

MAIL:  
Fletcher Allen Health Care
Development Office ? 461OH4
1 South Prospect Street
Burlington, VT 05401




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